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    Pomr (Problem Oriented Medical Record) : Cue and Clue PL Idx PDX PTX Pmo&Ed

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    DoctoRides 46
    Mrs. K is a 63-year-old woman admitted to the ward for type 2 diabetes mellitus, chronic kidney disease stage 5, hypertension, cirrhosis with ascites, and mild hyperkalemia. Her medical problems include a 20-year history of diabetes and hypertension. She requires bed rest, modified diets, and medication management for her conditions. Her vital signs, laboratory results, and education on her diseases will be monitored during her hospital stay.

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    Pomr (Problem Oriented Medical Record) : Cue and Clue PL Idx PDX PTX Pmo&Ed

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    DoctoRides 46
    366 views4 pages
    Mrs. K is a 63-year-old woman admitted to the ward for type 2 diabetes mellitus, chronic kidney disease stage 5, hypertension, cirrhosis with ascites, and mild hyperkalemia. Her medical problems include a 20-year history of diabetes and hypertension. She requires bed rest, modified diets, and medication management for her conditions. Her vital signs, laboratory results, and education on her diseases will be monitored during her hospital stay.

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    pomr

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    POMR fikri 5-7

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    Mrs. K is a 63-year-old woman admitted to the ward for type 2 diabetes mellitus, chronic kidney disease stage 5, hypertension, cirrhosis with ascites, and mild hyperkalemia. Her medical problems include a 20-year history of diabetes and hypertension. She requires bed rest, modified diets, and medication management for her conditions. Her vital signs, laboratory results, and education on her diseases will be monitored during her hospital stay.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    366 views4 pages

    Pomr (Problem Oriented Medical Record) : Cue and Clue PL Idx PDX PTX Pmo&Ed

    Uploaded by

    DoctoRides 46
    Mrs. K is a 63-year-old woman admitted to the ward for type 2 diabetes mellitus, chronic kidney disease stage 5, hypertension, cirrhosis with ascites, and mild hyperkalemia. Her medical problems include a 20-year history of diabetes and hypertension. She requires bed rest, modified diets, and medication management for her conditions. Her vital signs, laboratory results, and education on her diseases will be monitored during her hospital stay.

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    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
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    POMR (Problem Oriented Medical Record)

    CUE AND CLUE PL IDx PDx PTx PMo&Ed


    Mrs. K/63 yo/ward 28 bed 39 5. Type 2 DIabetes Non Pharmacology : PMO
    Mellitus - bed rest s,VS,
    Subjective : - DM diet 1700 kcal/day FPG/2hPPG
    -T2DM since 20 years, never
    took any medicine Pharmacology : P.ed
    -general weakness - OAD wait for FPG/2hPPG educate
    about T2DM
    Objective
    look moderate ill

    Laboratory :
    RBS: 98 mg/dl
    POMR (Problem Oriented Medical Record)
    CUE AND CLUE PL IDx PDx PTx PMo&Ed
    Mrs. K/63 yo/ward 28 bed 39 6. CKD st 5 6.1 HTN -renal biopsy Non Pharmacology : PMO
    6.2 DKD - bed rest s,VS, Ur/Cr
    Subjective : - avoid nephrotoxic drugs
    -renal failure (+) 3 months ago - renal diet 1700 kcal/day, low P.ed
    -T2DM since 20 years ago salt 2g/day, protein 0,6-0,8 low salt dt,
    -HT since 20 years ago kgBW/day limit water
    intake
    Objective Pharmacology :
    look moderate ill GCS 456 -
    BP 130/80 mmHg

    Laboratory :
    Ur/Cr: 109,9/3,27
    Hb: 11
    POMR (Problem Oriented Medical Record)
    CUE AND CLUE PL IDx PDx PTx PMo&Ed
    Mrs. K/63 yo/ward 28 bed 39 7. Mild 7.1 decrease of Non Pharmacology : PMO
    hyperkalemia renal excretion - bed rest s,VS, SE
    Subjective :
    -general weakness Pharmacology : P.ed
    -Ca polystyrene sulfonate 3x5 education
    Objective grams about patient
    look moderate ill GCS 456 disease

    Laboratory :
    Kalium: 5,28
    Non B non C hepatitis NAFLD

    Ascites
    Cirrhosis Hepatis

    Hyperkalemia
    CKD stage 5

    Hypertension stage 2 T2DM

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